Syringe Services 

Programs

A Technical Package of Effective 

Strategies and Approaches for Planning, 

Design, and Implementation

DEVELOPED BY

Zulqarnain Javed, PhD, MPH1

Katie Burk, MPH2

Shelley Facente, PhDc, MPH2

Laura Pegram, MPH, MSW2

Aliyah Ali, MPH3

Alice Asher, RN, PhD3

1 Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia

2 NASTAD, Washington, District of Columbia

3 National Center for HIV/AIDS, Hepatitis, STD and TB Prevention, Centers for Disease Control and 

Prevention, Atlanta, GA

2020
Acknowledgments 

This document was developed by the National Alliance of State and Territorial AIDS Directors 

(NASTAD), under funding announcement CDC-RFA-OT18-1802 for, and in collaboration with, the 

Centers for Disease Control and Prevention (CDC). This project was informed and reviewed by 

many subject matter experts. Special thanks to the following contributors. Christopher Abert, Lillie 

Armstrong, Aaron Arnold, Alice Bell, Danae Bixler, Dita Broz, Heather Bush, Lauren Canary, Robert 

Childs, Allan Clear, Haley Coles, Natalie Cramer, Donald Davis, Sarah Deutsch, Maya Doe-Simkins, 

Zachary Ford, Kirsten Forseth, Nora Maria Fuller, Rebecca Goldberg, Carol Helwig, Mary Howe, 

Miss Ian, Grace Keller, Michael Kilkenny, Paul LaKosky, Pamela Lynch, Kerry Nolte, Mary Pounder, 

Lisa Raville, Daniel Raymond, Amanda Reese, Patrick Rezac, Monica Ridgeway, Christine Rodriguez, 

Alessandra Ross, Shoshanna Scholar, Hansel Tookes, Rafi Torruella, Gretchen Weiss, Brandie Wilson, 

Sarah Ziegenhorn, Sara Zeigler, and Dominick Zurlo.

This technical package is a product of the US Department of Health and Human Services, Centers for 

Disease Control and Prevention (CDC), located in Atlanta, Georgia. 

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official 

position of the Centers for Disease Control and Prevention.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the National Center 

for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, the Public Health Service, or the US Department of Health and Human 

Services.

Links to nonfederal organizations are provided solely as a service to our users. These links do not constitute an endorsement of 

these organizations nor their programs by the Centers for Disease Control and Prevention (CDC) or the federal government, and 

none should be inferred. CDC is not responsible for the content contained at these sites.

Suggested Citation 

Javed, Z., Burk, K., Facente, S., Pegram, L., Ali, A. & Asher, A. (2020). Syringe Services Programs: A 

Technical Package of Effective Strategies and Approaches for Planning, Design, and Implementation. 

Atlanta, GA: US Department of Health and Human Services, National Center for HIV/AIDS, Viral 

Hepatitis, STD and TB Prevention, Centers for Disease, Control and Prevention; 2020.
Contents

Overview 1

Background 1

Framework 1

Guidance for Use 1

Benefits of Using this Document 2

Key Terms 2

Strategy I: Involve people with lived experience of the 

issues impacting your target population 5

Approach 1: Involve PWID in All Aspects of Program Design, Implementation, 

and Service Delivery 6

Approach 2: Create Meaningful Engagement and Service Delivery Opportunities 

for People with Lived Experience 6

Voices from the Field 7

Strategy II: SSP Planning, Design, and Implementation 8

Approach 1: Needs-based Syringe Distribution is the Best Approach 9

Approach 2: Delivery Model Must be Informed by Thorough Needs Assessment 10

Approach 3: Partnerships are Key to Successful SSP Implementation 11

Approach 4: SSPs Should Link PWID to Care, Whenever Possible 11

Voices from the Field 13

Strategy III: Core Versus Expanded Services 14

Approach 1: Syringe Distribution and Safe Disposal are Core SSP Services 15

Approach 2: Expanded Services Complement Core Services and 

Establish Continuum of Care 15

Voices from the Field 17

Strategy IV: Collect Data to Inform Program Planning 

and Evaluation 18

Approach 1: All SSPs Should Collect Data on Trends, Needs, and Overall 

Program Effectiveness 18

Approach 2: Data Collection Should Be Minimal 19

Voices from the Field 20

Strategy V: Sustainability 20

Approach 1: Foster Relationships with a Variety of Stakeholders 21

Approach 2: Create a Sense of Shared Purpose to Reduce Stigma 22

Voices from the Field 23

Additional Resources 24

References 27
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 1

Overview

Background

This technical package provides evidence of the 

effectiveness of strategies and approaches for 

supporting successful planning, design, implementation, 

and sustainability of syringe services programs (SSPs). 

This document was developed by the Centers for 

Disease Control and Prevention’s (CDC) National Center 

for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 

in partnership with the National Alliance of State and 

Territorial AIDS Directors (NASTAD). It provides a 

broad framework for new and existing SSPs to ensure 

needs-based service delivery, reduce harms related to 

injection drug use, and link participants to services that 

support their health and wellness. This was developed 

through a review of scientific literature as well as from 

the experiences and current practices of a diverse mix 

of SSP directors, key stakeholders, and experts in harm 

reduction. 

Technical packages are a key components of effective 

public health program implementation.1 Technical 

packages are designed to outline key proven 

interventions within a given public health program. 

This document was developed to highlight strategies 

with SSP implementation and service delivery that are 

known to be effective, to help users avoid the tendency 

of many public health programs to adapt a scattershot 

of interventions, some of which might have only a 

small impact. Technical packages are intended to be 

reference guides, not manuals. This document provides 

references and resources for more information about 

any topic presented so that readers can gain a deeper 

understanding, if desired. 

Framework

We identify five main strategies for supporting new 

and existing SSPs including involving people with lived 

experience; planning, design, and implementation; 

providing core versus expanded services; collecting 

data to inform planning and evaluation; and ensuring 

program sustainability. Each strategy includes the 

following key components:

• Key Takeaways foreshadows section content. 

• Approach describes how to make the strategy work.

• Evidence of Effectiveness in Achieving Intended 

Outcomes are the expected results of putting each 

strategy into practice, providing evidence from the 

literature demonstrating the effectiveness of the 

strategy. 

• Voices from the Field include perspectives and 

opinions from key stakeholders and current 

SSP providers regarding their experiences in 

implementing the strategy. 

Table 1 outlines major strategies and approaches, which 

are discussed in detail in respective sections. 

Guidance for Use

This technical package is a resource for use by health 

departments, community-based organizations, and 

diverse stakeholders to guide effective SSP design, 

implementation, and service delivery. The technical 

package provides evidence that the recommended 

strategies and approaches are effective in achieving 

the expected outcomes. SSPs can choose to use (or not 

use) the strategies and approaches supported by the 

evidence of effectiveness presented. The elements of 

this technical package are not intended to be used as 

standards for making decisions to open a new program 

or to close an existing program. New SSPs can use the 

technical package to ensure effective planning, design, 

and implementation; existing programs can use the 

document to identify program operations that need 

improvement or identifying opportunities for program 

enhancement. 

Because of the unique needs of people who inject drugs 

(PWID) as well as local and regional variation in policies, 

politics, and resources, this document is not intended 

to be used to provide standards of practice for SSP 

operations. Based on the current status of the evidence 

on SSPs and the dynamic nature of SSP implementation 

locally, standardized models are not described. 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 2

Benefits of Using this Document 

This technical package is a vital steppingstone toward 

establishing guiding principles and strategies to design 

SSPs and assess performance management, program 

evaluation, and continuous quality improvement in the 

provision of intended services. By identifying evidencebased interventions and describing how programs have 

implemented them in a real-world setting, users are 

provided with the information needed to establish a 

successful program that engages clients, meets their 

comprehensive needs, and has strong stakeholder 

support. 

Key Terms

1:1 exchange — a practice of restricting syringe access 

by providing a participant only the number of syringes 

that the participant returns to the SSP for disposal 

(not a recommended practice — see needs-based 

distribution).

Booting — an injection practice whereby a person 

repeatedly plunges and adjusts the volume of substance 

in a syringe more than once during a single injection 

episode. Booting has been shown to be preventive 

against accidental overdose and can create a more 

prolonged and pleasurable drug effect. Booting is 

not possible with retractable syringes, which are not 

recommended for distribution within SSPs.

Harm reduction — an approach to policies, programs, 

or practices that aim to reduce the negative health and 

social impacts of substance use.

Hepatitis C virus (HCV) — a curable, chronic infection 

spread through infected blood that attacks the liver and 

over time can lead to cirrhosis or cancer of the liver if 

left untreated.

HIV — human immunodeficiency virus; an incurable 

virus spread through infected blood, semen, vaginal 

fluids, or breast milk that attacks the immune system. 

HIV is manageable with medications but is often fatal if 

not appropriately treated.

Injection equipment (aka works) — equipment involved 

in injecting drugs including cookers, cottons, water, and 

alcohol wipes. This equipment is typically distributed 

along with syringes at an SSP to prevent bloodborne 

disease transmission.

Medications for treating opioid use disorder (MOUD) 

— the use of medications, such as methadone, 

buprenorphine, or naltrexone, to treat opioid use 

disorder. Previously referred to as medication-assisted 

treatment (MAT)

Naloxone (Narcan) — a synthetic drug that rapidly 

reverses an opiate overdose, by blocking opiate 

receptors in the nervous system. Naloxone can be 

injected into a muscle or sprayed into the nose, 

depending on the packaging of the drug. It is nonaddictive, safe, and can be administered with minimal 

training.

Needle exchange — another term for SSPs, less 

preferred by some because of its focus on needle 

distribution (less accurate than syringe distribution) 

and implication of 1:1 exchange (not a recommended 

practice).

Needs-based distribution — a syringe distribution 

practice that allows participants as many syringes as 

they say they need, regardless of how many syringes 

they return to the SSP for disposal. A best practice, for 

contrast, see 1:1 exchange.

Overdose — a biological response to too much of a 

substance or mix of substances; can be fatal (a type of 

poisoning).

People who use drugs (PWUD) — an acronym used to 

refer to people who use drugs, and generally preferred 

as “person-first” non-stigmatizing language.

People who inject drugs (PWID) — an acronym used to 

refer to people who inject drugs and generally preferred 

as “person-first” non-stigmatizing language, which is not 

recommended.

People with lived experience — while this term can 

be used more broadly, in the SSP context, it is used to 

refer to a person with current or former experience of 

substance use, typically a PWID.
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 3

Pre-Exposure Prophylaxis (PrEP) — a medication for 

people at high risk for HIV infection, to prevent them 

from acquiring HIV when exposed. This currently 

requires a daily oral pill, but other treatments are in 

development and testing, including a long-acting 

injectable medication.

Retractable syringes — syringes that are designed to be 

single-use only, primarily created to reduce the chance 

of accidental needlesticks in healthcare settings. The 

use of these types of syringes are discouraged for SSP 

distribution due to being less preferred by most PWID 

and coming with higher risk for overdose (see Booting).

Secondary syringe exchange — a practice through 

which SSP participants distribute sterile syringes and 

injection equipment to peers within their social and 

drug-using networks who cannot or will not attend 

SSPs; often secondary exchangers also collect used 

syringes for safe disposal.

Single-use syringes — see Retractable syringes.

Syringe Services Program (SSP) — a term for harm 

reduction programs where syringes and other safer 

injection and drug use equipment are distributed and 

collected for safe disposal, often with other medical 

and social services designed to improve the health of 

PWUD. Syringe services are provided free of charge.

Substance use disorder (SUD) — a condition defined 

in the Diagnostic and Statistical Manual of Mental 

Disorders (DSM)-5 that refers to the loss of ability to 

control the use of a legal or illegal drug coupled with 

continued use despite negative consequences. In 

most cases this term is preferred over the older term 

drug addiction (https://ajp.psychiatryonline.org/doi/

full/10.1176/appi.ajp.2013.12060782).

Syringe exchange program — another term for SSPs, 

less preferred by some because of its sole focus on 

syringes and implication of 1:1 “exchange” (not a 

recommended practice).
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 4

Table 1. Strategies and approaches for SSP design, 

implementation, and sustainability.

STRATEGY APPROACH

Involve people with lived 

experience of injection drug 

use, substance use disorder, 

homelessness, or other pervasive 

issues affecting the population 

served 

• Involve PWID in all phases of program design, implementation, and 

evaluation

• Create meaningful engagement opportunities to encourage participant 

ownership of program

• Recognize the expertise of SSP participants and compensate 

appropriately 

Planning, design, and 

implementation

• Needs-based distribution is the best approach

• Delivery model should be informed by thorough and ongoing needs 

assessment

• Partnerships are key to successful SSP implementation

• SSPs should link PWID to care, whenever possible and desired

Providing core versus expanded 

services

• Syringe distribution and safe disposal education are core services

• Expanded services complement core services and establish continuum of 

care. Broadly, these include

– Naloxone distribution and training 

– Infectious disease screening and/or treatment, or immediate linkage 

to care 

– Other expanded services 

Collecting data to inform planning, 

implementation, and evaluation 

• SSPs should collect data on trends, needs, and overall program 

effectiveness

• Data collection should be sufficient to meet needs and never a barrier 

to service delivery

Ensuring program sustainability • Foster relationships with a variety of stakeholders to increase and 

diversify community support, both financially and socially 

• Street outreach fosters relationships with clients and neighbors when 

they see services being provided

• Diversify funding sources for increased program sustainability

• Create a sense of shared purpose with the community to reduce stigma 

for both SSPs and the communities they serve
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 5

Involve People with Lived Experience of the STRATEGY I Issues Impacting Your Target Populations

Syringe services programs (SSPs) were first developed 

by people who inject drugs, to help keep friends 

and community members safe and healthy. Health 

departments, community-based organizations, clinics, 

and outreach teams adopted the practice and adapted 

it to fit within their institutions. It is important for 

SSPs today begin by centering their work on people 

who inject drugs (PWID). The PWID SSPs serve are 

the most important part of an SSP and are one of the 

primary sources of information, guidance, and insight 

for program design, implementation, and evaluation. 

Meaningful involvement of people with lived experience 

in these aspects is key to program success. This 

approach centers PWID as fundamental partners, 

teachers, and decision makers as well as service 

recipients, which enhances program reach, strengthens 

partnerships, and builds trust and a sense of ownership. 

Former PWID who no longer inject drugs may be 

among PWID with relevant lived experiences, but 

ensuring that the needs, interests, and understanding of 

current PWID are well-represented is crucial. Coalition 

building and community consultation are key to SSP 

acceptance and sustainability, and should include a 

wide variety of community stakeholders encompass 

communities of people who use drugs.2 PWID 

involvement models, including secondary peer exchange 

as well as approaches such as PWID employment within 

SSPs, have significant public health benefits and present 

opportunities to enhance overall program effectiveness. 

KEY TAKEAWAYS

✔ Involve participants in all aspects of program 

design, implementation, and service delivery.

✔ Consult, empower, and provide thoughtful 

support to all participants.

✔ Create meaningful engagement opportunities, 

ranging from short-term roles to consulting, 

committee/board membership, paid peer 

distribution programs (secondary exchange), and 

long-term employment.

✔ Commit to learning from PWID in order to train 

staff on key concerns affecting participants and 

help shape programming to be useful, effective, 

and respectful of participant autonomy.

✔ Acknowledge PWID experience as an invaluable 

resource — ideally, SSPs will provide PWID 

compensation for their time. 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 6

Approaches 

To maximize individual and public health benefits, PWID ideally should be involved in all aspects of SSP design and 

implementation. SSPs should recognize the immense value of participant engagement, feedback, and leadership 

and create opportunities for involvement in various aspects of the program. The following sections discuss key 

approaches for effective engagement and meaningful involvement of PWID. Each approach is discussed in the 

context of evidence and intended outcomes. 

Involve PWID in All Aspects of Program Design, Implementation, and APPROACH 1 Service Delivery

A recent CDC review of evidence-based SSP strategies 

indicates SSPs are most likely to be successful when 

the needs and concerns of the local PWID communities 

are addressed.3 Participant involvement can provide 

important insights into local conditions, needs, and 

resources and is critical for program design and 

planning. PWID knowledge and personal experience, 

whether past or current, help guide resource allocation 

and service provision. Further, the unique expertise 

offered by people with relevant lived experience are 

invaluable from an implementation and evaluation 

standpoint. Ideally, SSPs should offer PWID a range of 

options for levels of participation. 

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Inform program design, implementation, and service 

delivery

• Peers and PWID provide unique insights into 

community needs and preferences; peer involvement 

is vital to designing programs that meet PWID 

needs.4,5 

• People with lived experience can help expand SSP 

outreach to communities with whom the SSP might 

be having difficulty establishing relationships.6,7

• Peer involvement facilitates both core and expanded 

services delivery, including syringe distribution and 

naloxone administration.8

• Participant involvement informs challenges faced 

by specific populations and serves as a bridge to 

those groups. Peers who have experienced, or 

are experiencing, similar issues to the participant 

population are of particular importance. Ashford et 

al.8 reported that PWID experiencing homelessness, 

on probation or parole and having prior mental 

health disorders were least likely to interact with 

peers, whereas PWID with human immunodeficiency 

virus (HIV) were most likely to interact. 

Improve individual and population health outcomes 

• Richardson et al.reported that employment was 

associated with over 50% reduction in risk of 

mortality among persons who use drugs (PWUD) 

with HIV.9

• Participants report better treatment, greater 

satisfaction, deeper engagement, and better health 

outcomes as a result of interaction with their 

peers.10,11

Create Meaningful Engagement and Service Delivery Opportunities for APPROACH 2 People with Lived Experience 

Meaningful PWID engagement builds peer networks 

and creates an environment of collaboration and 

knowledge sharing. It demonstrates a program’s 

commitment to community health and well-being, 

utilizes PWID expertise to expand program reach, 

deepens staff knowledge, and has demonstrated 

individual and broader public health benefits such 

as reduced risk of disease transmission, reduced 

mortality, and overall improved health outcomes.9–12

Such involvement can create and reinforce a sense 

of program ownership among participants through 

shared decision making. Possible engagement 

opportunities can range from participation in feedback 

groups to short-term employment as well as longterm, full-time roles with the SSP, including executive 

leadership, serving on a community advisory board, and 

participating as secondary exchangers. Ideally, SSPs will 

pay all individuals with lived experience for their time. A 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 7

bidirectional relationship that recognizes and respects 

peers as professionals can be motivating for participants 

and beneficial for the program. 

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Enhance trust with PWID; build community networks

• Bardwell et al.reported that monetary compensation 

of PWID’s time and involvement with an SSP 

reduced participants’ perception of stigma.13

• Engagement of people with lived experience 

in service provision has been shown to foster 

connections to their community,14 build confidence 

and empowerment, and improve wellness.15,16

Encourage participant ownership through meaningful 

engagement

• A recent study of PWID employed at a 

comprehensive harm reduction program found 

that participants view monetary compensation as 

acknowledgement of their time and skills and report 

increased social connection and a sense of collective 

purpose.13 

• An open, welcoming environment and a range of 

engagement options for participants are at the heart 

of a successful international harm reduction program 

(COUNTERfit), which is managed exclusively by 

people with lived experience.4

VOICES FROM THE FIELD

“Listen to drug users. To your participants. They are 

participants. They are not clients; they are definitely 

not patients. And as participants they should be part of 

your decision-making process. Have them part of your 

board, have them part of your decision-making. Even 

if it’s just making sure [you are] constantly asking your 

participants what’s working and what’s not.” 

– Community-Based SSP Director, Puerto Rico

 “If you want these programs and the people who 

run them, particularly if they’re from the population 

served, to be leaders in this specific way, there’s 

a lot of training and technical support, program 

development support that needs to happen to support 

them as true leaders in this work.” 

– Community-Based SSP Director, California

“I think that’s part of our job in this world, to create 

employment opportunities and sustain people in them 

so they can move beyond for the next step of their 

lives.” 

– Community-Based SSP Director, California

“I want to be very clear that peer is not a level of a 

position in an organization. Peer — peer educator, 

being a peer drug user, post-drug user, it’s a vantage 

point, or positioning that this person has vis-à-vis 

drug use, sex work, homelessness, whatever. Peer is 

a vantage point, not a position. I just want to make 

sure I take a position on this — many times peers are 

seen as, that’s the lowest position, a peer, and then 

you graduate to being an outreach worker, and then a 

coordinator. No, ours are peer outreach workers. Like 

an outreach worker with a peer perspective. Hopefully, 

someday we’ll have a peer Executive Director.” 

– Community-Based SSP Director, Puerto Rico
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 8

STRATEGY II SSP Planning, Design, and Implementation

SSP planning, design, and implementation are 

challenging activities. Those activities are more likely to 

be effective if they are based on a careful assessment 

of the needs of the target population for syringe 

services and the available and needed resources of 

other key stakeholders in the SSP. Overly complex 

needs assessments can create barriers to and delays 

in providing timely services for PWID. Meeting the 

immediate needs of the PWID community should 

be given higher priority and balanced with ongoing 

needs assessment for program modification. Ideally, 

SSP design should be a collaborative process that is 

informed by individuals who use the services provided. 

Program design should include interventions for 

reducing the effects of social determinants such as 

racism, poverty, stigma, and trauma on individual and 

community health. Evidence suggests that SSPs are 

more successful when they are planned as communitylevel public health interventions and not only 

interventions for individual PWID.2 

KEY TAKEAWAYS

✔ Syringe distribution and disposal options are 

essential (i.e., core) SSP services; programs should 

look for opportunities to link PWID to care where 

possible and desired.

✔ Needs-based distribution is the recommended 

syringe distribution practice. It reduces disease 

transmission and unsafe injection practices and 

enhances PWID trust and involvement.26,27 

✔ Ensure low-threshold access to services (i.e., 

maximize access in terms of number of locations, 

hours, etc.), ensure participant confidentiality, 

and minimize administrative burden (e.g., data 

collection).

2

✔ Secondary syringe exchange programs increase 

SSP reach and effectiveness; programs should 

offer peer educator training whenever possible.2

✔ Involve participants when determining the 

size and type of syringes to be distributed by 

the program. High-quality syringes protect 

participants’ health and improve program uptake.

✔ SSP design should accommodate the needs and 

concerns of the local PWID communities.2,26

✔ Partnerships are key to successful SSP 

implementation. Include diverse stakeholders 

in all aspects of planning, design, and 

implementation to ensure community 

understanding of SSP goals and create a 

sociolegal environment supportive of SSP.

✔ Offer assistance in accessing care for substance 

use disorders or for other physical or mental 

health concerns. Whenever possible, provide 

and/or coordinate provision of other health and 

social services, especially for PWID who do not 

receive care elsewhere.2,26
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 9

Approaches 

A clear approach to achieving intended health goals is essential for overall program success. The approaches 

discussed in the following highlight integral components of an effective SSP and are designed to guide various 

aspects of program planning, design, and implementation. 

APPROACH 1 Needs-Based Syringe Distribution is the Best Approach 

Needs-based distribution is the most effective syringe 

distribution model, both in terms of syringe coverage 

(ensuring adequate supplies are available for sterile 

injection) and disease prevention. It builds a culture of 

trust and inclusivity with the participants and values 

them as essential stakeholders in the decision-making 

process. In addition, needs-based distribution supports 

secondary syringe exchange, which broadens program 

reach and improves overall effectiveness. Although 

restrictive syringe distribution approaches such as 

1:1 exchange may seem desirable, in fact, they are 

associated with increased syringe sharing and increased 

risk of infections among PWID and are therefore not

recommended. In addition, PWID face multiple barriers 

to care; SSPs should strive to address such challenges 

and provide low-threshold access to services.

Other things to consider: The size and type of syringes 

are important from both a harm reduction and 

participant preference standpoint. High quality, 

nonretractable syringes reduce the risk of disease 

transmission; programs are encouraged to acquire 

participant feedback before syringe distribution. 

Providing participants with safer injection and vein 

care education is also recommended as this will 

decrease skin and soft tissue infections and other 

injection-related injury. Further, programs should 

ensure safe syringe disposal to reduce the spread of 

infectious disease and potential for syringe reuse within 

communities of people who use drugs. Disposal options 

should be provided onsite through portable sharps 

containers, and safe disposal education. 

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Infectious disease prevention

• Kerr et al.reported an over 90% lower risk of HIV 

associated with unlimited syringe distribution 

practices.17

• Several studies have linked a restrictive 1:1 syringe 

exchange policy to the HIV epidemic among PWID 

in Canada in the mid-1990s.18–20

Improved syringe coverage

• Bluthenthal et al.reported that syringe coverage 

rates (or adequate access to sterile injection supplies 

for each injection) were lowest for 1:1 exchange and 

highest for needs-based distribution policies.21

Safer injection and syringe disposal

• Kral et al. found that participants of needs-based 

SSPs were approximately half as likely to reuse 

syringes than participants of SSPs with more 

restrictive dispensation policies.22

• Bluthenthal and colleagues found that increasing the 

numbers of syringes participants receive from SSPs 

does not result in increased odds of unsafe syringe 

disposal.23

• Quinn and colleagues revealed that receiving more 

than 30 syringes in the past 30 days was associated 

with a lower chance that participants disposed of 

syringes improperly.24

Community buy-in and increased program reach

• PWID who serve as secondary exchangers can 

provide safer injection materials, information, and 

education to their peers who are not coming to 

SSPs.25–27

• Wood et al. found that a peer-run secondary 

exchange program reached a particularly vulnerable 

PWID population and was associated with nearly 

3-fold increased likelihood of safe syringe disposal.11
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 10

APPROACH 2 Delivery Model Should Be Informed by Thorough Needs Assessment 

SSPs can take on a variety of designs such as a fixed 

site storefront model, a van or backpack-based mobile 

outreach model, or a secondary exchange model 

powered by participants themselves. Certain models 

are better suited for different environments, e.g. mobile 

outreach models for rural areas while others might be 

better suited to provide wrap-around support services. 

For example, offering rapid hepatitis C virus testing 

as part of backpack-based mobile SSP is difficult. 

A thorough needs assessment that includes people 

intending to use the services, can help determine 

what program model or models to employ. Needs 

assessments should be carried out in a periodic or 

ongoing way to adapt programming to changing 

and emerging needs. Suggested needs assessment 

components include, when possible: 

• Need: PWID prevalence; infectious disease 

rates among communities of PWID and 

surrounding community, environmental factors 

that may influence drug use; prevalence of other 

comorbidities (e.g, mental illness, homelessness, 

hepatitis B virus, etc.) 

• PWID characteristics: age, race/ethnicity, sex or 

gender identify, cultural and linguistic barriers, 

vulnerable populations, drug use characteristics

• Populations with increased vulnerability: 

adolescents, elderly, pregnant people, racial/ethnic 

and sexual minorities, individuals with comorbid 

mental health disorders, and people experiencing 

poverty or homelessness

• Resources: workforce and funding (available/

required) 

• Partnerships: health departments; local, state, or 

national agencies; community-based organizations; 

substance use disorder treatment programs; elected 

officials; and public safety 

• Local policies, politics, and practices: community/

political/agency support, legal barriers to SSPs

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Greater understanding of local PWID needs/demands

• In their study of nearly 500 PWID from 13 SSPs in 

New York City, Heller et al. reported that younger 

and homeless PWID were at greater risk of receiving 

an inadequate number of syringes and concluded 

that partnerships with law enforcement and 

homeless services was key to addressing the local 

“syringe gap.”28

• Multiple local factors affect participants’ ability to 

access SSPs. Designing services by considering the 

local context — both local, individual-level PWID 

characteristics and the structural (physical and 

political environment) — is vital for success.21,28,29

Informed SSP design and resource allocation

• Downing et al. studied syringe distribution models in 

nine different US cities and reported that coalition 

building and community consultation were key to 

program acceptability and sustainability.2

• A peer-run, night-time SSP established in the heart 

of Vancouver’s open drug scene reached PWID at 

highest risk of HIV infection and improved syringe 

disposal practices.12

• The know-your-epidemic, know-your-response 

philosophy has been instrumental in addressing the 

HIV epidemic globally — lessons learned should 

inform SSP needs assessment and service delivery.30

Reduced health disparities and improved PWID health 

and well-being

• In response to the opioid crisis, Safe Recovery ─ the 

largest SSP in Vermont ─ partnered with the state 

to offer low-threshold buprenorphine in an effort 

to integrate addiction treatment with the broader 

healthcare system. Since October 2018, over 87 

participants have initiated treatment.31

• A nurse-led health promotion program in New 

Jersey32 offers a range of reproductive and 

preventive treatment services in an SSP setting to 

reduce perinatal HIV transmission among a pregnant 

population at high risk. 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 11

APPROACH 3 Partnerships Are Key to Successful SSP Implementation

Ensuring buy-in among from a wide range of 

stakeholders, especially public safety, can play a 

principal role in addressing community opposition and 

stigma associated with SSPs and provide important 

insights into considerations for long-term program 

sustainability. In addition, relationships with key 

community and local, state, and national partners 

are important for ensuring successful SSP planning, 

design, and implementation. Input from stakeholders — 

including local PWID communities, community-based 

organizations, health departments, local businesses, 

neighborhood residents, and public safety — offers 

valuable knowledge and helps identify and address 

major barriers at each stage of SSP design and delivery. 

The resulting knowledge is vital for program planning 

and efficient resource allocation. (See section V for a 

detailed discussion on partnerships and sustainability). 

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Understand local needs; identify barriers and 

opportunities

• As a first step in establishing SSPs, health 

departments and other local partners, including 

existing SSPs and HIV prevention planning groups, 

can provide important information such as burden 

of HIV, HCV, HBV and possibly demographic 

characteristics of communities of people who inject 

drugs.3

• Partnerships with public safety, faith-based 

organizations, neighborhood representatives, 

community organizations, and business owners 

help identify major concerns and challenges to 

both design and delivery; relationships with health 

departments, local businesses, and medical or 

social services can help with delivery of expanded 

services.5, 11 

• Partnerships with networks of people who have 

current and past drug injection experience can help 

establish secondary syringe exchange programs and 

improve the overall effectiveness of SSPs.3, 5, 11 

Use partnerships to address stigma and maximize 

health benefits

• Public safety champions can play an important role 

in shifting attitudes and beliefs regarding SSPs by 

helping programs connect PWID to treatment, as 

opposed to a strict criminal legal approach.3,18 

• Barocas et al. reported that previously incarcerated 

SSP participants had high risk for opioid overdose, 

compared with those without prior incarceration; 

however, they were also more likely to use naloxone 

for overdose prevention, highlighting the importance 

of buy-in from law enforcement and corrections to 

connect such vulnerable populations to care (See 

Section III for a discussion of “core” vs “expanded” SSP 

services).19 

• Making collaboration a key strategy and establishing 

relationships with government, legal, medical, and 

other relevant stakeholders is recommended as an 

evidence-based, guiding principle to successfully 

address the opioid overdose crisis.3 

APPROACH 4 SSPs Should Link PWID to Care, Whenever Possible 

While syringe distribution and disposal are at the core 

of any SSP, linkage to physical and behavioral health 

services is important from both an infection control 

and a broader harm reduction standpoint. Additionally, 

it should be recognized that SSPs are an important 

resource that PWID are often referred to and valued as 

such.

Care linkage serves as a crucial mechanism in merging 

substance use disorder treatment with traditional 

healthcare services and establishes a continuum of 

care, especially for participants who are not receiving 

care elsewhere. Further, a coordinated care approach 

can help identify highly marginalized populations and 

help tailor services accordingly. Identifying community 

resources and services that are willing to work with 

communities of PWID can be challenging, yet ongoing 

effort to build these partnerships is vital to improve the 

health of PWID. The following services can be provided 

either directly by the local SSP or through a partnering 

agency: 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 12

• Education about safer injection techniques, overdose 

prevention, viral hepatitis, HIV, and other challenges 

relevant to participants’ health.

• Naloxone distribution and training.

• Onsite access or immediate referral or linkage to 

care to

– substance use disorder treatment 

– low-threshold or onsite medication to treat opioid 

use disorder (MOUD)

– HIV, viral hepatitis, and STD testing, care and 

treatment, including HIV PrEP (Pre-Exposure 

Prophylaxis) 

– basic wound care and/or advice and consultation.

• Vaccinations for hepatitis A and B viruses, human 

papillomavirus, influenza, pneumonia, and tetanusdiphtheria-pertussis.

• Patient navigation.

• Mental health and/or harm reduction-based 

counseling.

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Access to additional health services for PWID health 

and wellbeing

• SSPs provide important opportunities to link PWID 

to care, especially for high risk PWID with little or no 

access to traditional healthcare providers.33–35

• CDC’s Evidence-Based Strategies for Preventing Opioid 

Overdose report recommends SSPs work best when 

appropriate care is provided for opioid use disorders 

(OUD) and other physical/mental health concerns.3

• Kidorf et al.reported that concurrent syringe 

exchange and substance use disorder treatment 

was associated with a 30% reduction in frequency 

of heroin use and a 20% reduction in injection drug 

use as well as reduced frequency of illegal activities 

and incarceration, compared with syringe exchange 

alone.35

• SSPs might also provide such other services as 

naloxone and medication-assisted therapy.

Establishing a continuum of care

• Successful SSP support services integration 

models can present important opportunities for 

learning. For example, through an innovative pilot 

program, Virginia’s behavioral health agency and the 

University of Virginia have partnered to provide HCV 

treatment via telemedicine at comprehensive harm 

reduction and opioid treatment programs.36

• The Access to Reproductive Care and HIV Services 

(ARCH) program successfully integrated reproductive 

and HIV care for high-risk pregnant people in five 

New Jersey cities and expanded over time to include 

hepatitis screening, immunizations, gonorrhea and 

chlamydia testing and treatment, and tuberculosis 

testing.33
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 13

VOICES FROM THE FIELD

“We used to have a 1:1+ exchange model — We 

gave people 30 syringes when they came originally, 

regardless of how many syringes they had, and then 

thereafter it was 1:1 with rounding up for packaging. 

And then a couple of years ago, we switched over 

to negotiated exchange. We had to do a regulation 

change in order to do this — We still encourage them 

to return their syringes to us. But what we found is 

that — before what would occur is people would try 

to come up with ways of scamming the system to 

get what they need. We were encouraging people to 

be dishonest with us about what they needed, and 

then they wouldn’t talk with us about other barriers 

or issues they were having. This was a real problem 

— [now] people are being much more honest with 

us. And not just about the syringes, but about other 

things. Because it’s not just about that talking, but 

having additional communication.” 

– Public Health Department SSP Coordinator, New Mexico

“We want to literally be able to go where people are at. 

We do this both physically, psychologically as much as 

we can, emotionally, and socially as much as we can. 

We come from a social justice perspective to harm 

reduction.” 

– Community-Based SSP Director, Puerto Rico

“You don’t understand harm reduction, if you’re saying, 

‘If you don’t bring me any, I won’t give you any.’ And 

some syringe exchanges here are literally like that. So 

there’s a real lack of knowledge of how harm reduction 

can and will affect the HIV epidemic — or really touch 

on the HCV epidemic. And more importantly, what 

are good policies for the participants, and what are 

good policies to push in society so we’re better to drug 

users?”

– Community-Based SSP Director, Puerto Rico

“I get that in some places the ONLY way to do syringe 

exchange at all is 1:1, and in those places that’s 

definitely better than nothing. But I think as soon 

as there’s a little window to push away from that, 

we all need be focused on getting away from those 

practices that can be so damaging — everyone has 

to be in that mindset that you are settling because of 

these constraints you can’t do anything about, and the 

second that you’re able to push, even if it’s a year or 

two later, you have some successes, you’re able to say, 

‘Remember before, you were skeptical, but look what 

I’m doing...’ You have to constantly strive to follow best 

practices.” 

– Community-Based SSP Director, Vermont

“The first advice I would give to new programs is that 

they need to have at least one, and probably ideally 

a series of focus groups, with active drug using 

participants or potential participants who can offer 

insight into exactly what materials people want and 

need. I really don’t think anything else will do — I 

don’t think it’s sufficient to pull together a list of local 

recovery coaches, or people who identify as being in 

recovery or having a history. I just don’t think that’s 

sufficient — Some things change really rapidly. That 

would be my first advice is do not even think about 

opening your doors before doing that — in a way that 

is respectful, and ideally pays people for their time and 

expertise.” 

– Harm Reduction Practitioner, Illinois and Michigan
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 14

STRATEGY III Core versus Expanded Services

Harm reduction is a basic tenet of an SSP. A 

combination of core and expanded services 

encompasses various facets of primary and secondary 

prevention, reduces harm, and improves the overall 

health and well-being of people who inject drugs and 

the community as a whole. While syringe distribution 

and disposal are core SSP services, expanded services 

(see Approach 2 in this section) can complement core 

services by providing unique opportunities to increase 

access to integrated care, especially for participants 

without a usual source of care. 

KEY TAKEAWAYS

✔ Syringe distribution and disposal options are core 

SSP services; expanded services complement 

core services and improve PWID health and wellbeing; while SSPs provide all core services, ideally 

and when possible, expanded services can also be 

provided. 

✔ Syringe distribution should be needs-based; 

ideally, syringes should be high quality and nonretractable.

✔ Safe disposal should be offered onsite; portable 

sharps containers should be provided whenever 

possible. If neither of these disposal options is 

possible then education about safe home disposal 

should be provided.

✔ Naloxone distribution and training is a lifesaving intervention demonstrated to reverse 

overdose and reduce mortality; naloxone should 

be provided directly to participants and their 

immediate networks whenever possible.

✔ Expanded services can act as a bridge between 

SSPs, Substance Use Disorder (SUD) treatment, 

and traditional medical care and help establish a 

continuum of care.

✔ Infectious disease screening/referral to 

treatment, education regarding safe injection 

practices, medication for opioid use disorder 

(MOUD), naloxone, and other supportive services 

are vital primary and secondary prevention 

approaches that help achieve the overall SSP 

purpose of reducing harms and improving the 

health of PWIDs.

✔ Ideally, programs will make efforts (e.g., establish 

partnerships and acquire funding) to offer 

expanded services to participants. Successful 

integrated care programs exist and offer valuable 

models for other programs.
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 15

Approaches 

Each community has its own unique needs based on a variety of demographic, social, and clinical factors. Similarly, 

each SSP has a unique capacity to provide services. However, an understanding of the minimum standard of 

services (i.e., core) and any additional services that support core services (i.e., expanded) and help achieve overall 

SSP goals is essential. The approaches following discuss the importance and relevance of each set of services.

APPROACH 1 Syringe Distribution and Safe Disposal are Core SSP Services

All SSPs should ensure syringe distribution, provision 

of injection equipment, and safe syringe disposal 

options. Syringe distribution should be needs-based 

(see Strategy I: Approach 1 for needs-based distribution 

practices). In addition, size and type of syringes are 

relevant from both a harm reduction and participant 

preference standpoint. Retractable syringes carry a 

high risk of overdose,37 are generally more difficult to 

use, and not preferred by participants.38 High quality, 

non-retractable syringes reduce the risk of disease 

transmission; programs are encouraged to acquire 

feedback from the local PWID community before 

syringe distribution to ensure services and supplies are 

appropriate and meet the community need. In addition, 

safe syringe disposal should be offered onsite, through 

provision of portable sharps containers or education 

about safe home disposal options. 

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Safe injection practices and reduced infectious disease 

transmission and injury

• Needs-based distribution is associated with greater 

syringe coverage and safer injection practices; 

restrictive syringe distribution increases risk of 

infectious disease transmission. (See Strategy I: 

Approach I for needs-based distribution practices.) 

• Single-use or retractable syringes increase the 

chance of overdose by preventing booting, which 

titrates the dose being injected’ (locking mechanism 

retracts the needle).2 Programs should provide high 

quality, non-retractable syringes.

Safe syringe acquisition and disposal

• Quinn et al. reported that receiving syringes at an 

SSP was associated with a significantly lower odds 

of improper syringe disposal compared to receiving 

syringes from other sources.25

• Coffin and et al.reported that reliable, sterile syringe 

acquisition was associated with a seven-fold higher 

odds of safe disposal. The study concluded that 

expanding SSP sites can improve safe disposal 

practices and that such initiatives should target 

injection drug users who do not access SSPs.38

• Bluthenthal et al. reported that increasing the 

number of syringes received from SSPs does not 

result in increased odds of unsafe syringe disposal.24

Expanded Services Complement Core Services and Establish Continuum APPROACH 2 of Care

Some PWID experience multiple, often co-occurring 

disorders that require a broad, collaborative approach to 

care. Various socioeconomic and demographic factors 

might further limit PWID’s access to care. In addition, 

PWID might have special treatment needs because 

of the type of substances used. SSPs present unique 

opportunities to provide and/or link PWID to care. 

This comprehensive, integrated care approach provides 

PWID with multiple health services under one roof and 

can act as a bridge between substance use disorder 

treatment and traditional healthcare. The resulting 

continuum of care benefits all PWID; however, the need 

and impact of increased service availability is highest for 

PWID who do not have a usual source of care.

Ideally, SSPs will provide various screening, diagnostic, 

and referral services, in addition to core services, so 

long as they do not interfere with the provision of core 

services. These services may be provided directly by the 

SSP or indirectly through referrals to local, regional, or 

co-located partnering. The following is a list of services 

that SSPs should consider providing: 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 16

• Education about safer injection techniques, overdose 

prevention, viral hepatitis, HIV, and other issues 

relevant to the health of participants.

• Naloxone distribution and training.

• Onsite access or immediate referral or linkage to 

care to the following:

– Substance use disorder (SUD) treatment. 

Additional resources and guidelines regarding 

SUD treatment for PWID can be found through 

the links below: 

https://findtreatment.samhsa.gov/

https://www.samhsa.gov/medication-assistedtreatment

https://www.cdc.gov/pwid/substance-treatment.

html.

– HIV, viral hepatitis, and STD testing, care, and 

treatment, including HIV PrEP (Pre-Exposure 

Prophylaxis). Additional information regarding 

testing and treatment practice guidelines are 

available at: 

https://www.cdc.gov/hiv/guidelines/index.html

https://www.cdc.gov/hepatitis/abc/

https://www.cdc.gov/pwid/disease-treatment.

html.

– Basic wound care, advice, or consultation.

• Vaccination for HAV, HBV, HPV, influenza, 

pneumococcal, and Tdap 

• Case management 

• Mental health and/or SUD counseling

• Harm reduction support groups

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Reduction in fatal opioid overdose

• The World Health Organization recommends that 

community distribution of naloxone be part of all 

comprehensive harm reduction programs.40

• Community placement of naloxone, including 

provision of naloxone directly to people who inject 

drugs, has been shown to be effective in preventing 

fatal opioid overdose.3,41,4

• Walley et al. reported reduced death rates in 

communities where overdose education and 

naloxone distribution were implemented.43

• Only 5–10 minutes of education are needed to 

train participants in effectively recognizing and 

responding to an overdose with the lifesaving drug 

naloxone.44

Access to care

• PWID who regularly use an SSP are five times as 

likely to enter treatment for a substance use disorder 

and nearly three times as likely to report reducing 

or discontinuing injection drug use, compared with 

those who have never used an SSP.45–47

• Kidorf et al. report that SSPs can be used to 

increase treatment interest and enrollment and even 

reenrollment after discharge.48

• Expanded buprenorphine treatment and linkage to 

social services were identified as major contributors 

to the success of a Philadelphia SSP.49

NALOXONE SAVES LIVES

✔ Naloxone is a life-saving medication that reverses opioid overdose and reduces mortality.

✔ Ideally, naloxone should be distributed directly to people who inject or otherwise use drugs.

✔ Naloxone should be free-of-charge and distributed in quantities that ensure adequate coverage within 

communities.

✔ Naloxone distribution should be accompanied by a short, simple training in its use and safety practices.

✔ Naloxone should be prioritized for active PWUD and their immediate networks.
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 17

VOICES FROM THE FIELD

“We try to make it as easy as possible for them to get 

them the services they need and not create barriers.” 

– Community-Based SSP Director, Utah

“If we do SSPs right, we need to keep harm reduction 

at the core of it. This is about the message of 

empowering drug users to take care of their own 

health, both at the individual and the collective level. 

If we’re not doing that, we’re missing it. It’s about 

empowerment. 

“Start small, don’t try to conquer the world. Do what 

you can, focus on strengthening process and your 

procedures.” 

– Community-Based SSP Director, Utah

“I would say needs-based distribution is great, but if 

that’s going to get in your way and keep you from 

starting because you’re scared about capacity, like, 

if you have to ration, you have to ration. It’s more 

important to be doing the work than it is to be 

perfect.” 

– Community-Based SSP Director, California

“It’s just nice to be able to offer people treatment. And 

with low barrier, they’re also not getting discharged 

for poly substance use, so they really feel like we’re 

hanging in there with them. And if they show up at 

4pm for a 2pm appointment, we still see them. It’s 

really the way it should be.” 

– Community-Based SSP Director, Vermont

“You have to look at your community and what’s going 

on. What’s the problem you need to solve? It isn’t one 

size fits all. In one community what you really need to 

be working on is academic detailing for prescribers, or 

some way to limit the prescriptions without sudden 

cessation, which we’re pretty convinced drives people 

to injection use. If you’ve got that problem – you 

might not have that much of an injection problem, you 

may have more of a need for support to enter drug 

treatment or maybe you need more testing and linkage 

to care services. Maybe you need telemedicine for 

MAT [medication-assisted treatment]. What will best 

serve your county?” 

– Health Department-Run SSP Director, West Virginia
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 18

Collect Data To Inform Program Planning and STRATEGY IV Evaluation

Data collection is a critical aspect of program planning 

and evaluation. Data is important to understanding 

what is needed versus what is available and what is 

working versus what is not (i.e., program evaluation). 

In addition, reliable data is an important component of 

an effective needs assessment. While data regarding 

major trends and performance indicators is helpful 

for planning and evaluation, data collection should 

neither distract from the primary mission of syringe 

distribution for participants nor act as a barrier to 

PWID participation. 

KEY TAKEAWAYS

✔ Data collection is essential to informing program 

planning and evaluation. Data should help 

programs better understand provided services 

and available resources in the context of local 

needs for people who inject drugs. 

✔ Efforts should be made to collect reliable data on 

key demographics, services provided, and trends 

in service utilization. 

✔ Data collection should be minimal and always 

serve a purpose. Participation in research 

activities should never be a requirement for 

participation in SSP. SSPs should strive to provide 

low-threshold services.

✔ Ongoing monitoring should include regular review 

of collected data to assess program effectiveness, 

with particular attention to reaching marginalized 

and/or highly stigmatized populations(e.g., people 

of color, women, and transgender persons).

Approaches 

Data can be used as a tool for improving program efficiency and overall effectiveness. Efforts that focus on 

collecting data related to services provided and population(s) served (e.g., number of people receiving services, 

demographics, etc.) provide insights into community needs and help direct efforts to address identified gaps or 

challenges. Data collection should be minimal to reduce participant and administrative burden and should never be 

a barrier to care. 

All SSPs Should Collect Data on Trends, Needs, and Overall Program APPROACH 1 Effectiveness

Collecting some types of data is necessary for 

understanding population needs and program efficacy. 

Minimal data collection can include the following:

• Number of people receiving services (e.g., syringes, 

testing, SUD treatment, etc.).

• Number of syringes/naloxone kits distributed.

• Number of individuals for whom each participant 

receives syringes (o collect the number of people 

served through each exchange interaction (i.e., 

secondary exchange coverage).

Minimal data collection can be supplemented with 

periodic efforts (e.g., annual/quarterly surveys) to 

capture data on additional factors such as participant 

demographics (e.g., age, race/ethnicity, and sex or 

gender identity) and emerging participant needs. Data 

that includes any potentially identifying information 

about participants should be stored in a secure, 

electronic database. Data may be collected either on 

paper forms or via mobile devices, to be transferred 

securely (i.e., through encryption) to the database later. 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 19

Periodic analysis of program data can help monitor 

progress and identify areas of improvement.

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Better understanding of community needs: improved 

program effectiveness

• Data can provide useful information regarding 

participant concerns and satisfaction and identify 

program strengths and areas for growth.51 

• Both qualitative and quantitative data are useful 

in identifying gaps in service provision, improving 

program services, and developing goals and 

objectives.51

• The Works Program in Boulder, Colorado — one 

of the oldest SSPs in the country — worked 

collaboratively with other SSPs and the state health 

department to design a centralized data collection 

system. Routine information (date, location, number 

of syringes collected/provided) is supplemented by 

annual participant surveys to assess trends in drug 

use.52

Ensuring program sustainability

• Both routine and supplemental data (e.g., PWID 

at high risk for mortality or morbidity, minority 

populations, stigma and other barriers to SSP 

services) can be used to track SSP progress and 

justify program presence; such information might 

be of interest to funders, regulators, and community 

stakeholders.51

APPROACH 2 Data Collection Should Be Minimal 

Efforts to collect data should neither distract from 

the program’s primary focus (i.e., syringe distribution) 

nor deter participants from seeking services. Further, 

participation in research or other activities should never 

be a requirement for SSP participation.16 Data collection 

should primarily focus on gathering crucial information 

on trends and program effectiveness. 

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Reduced burden of data collection

• The World Health Organization recommends that no 

data collection effort should be a burden on service 

delivery. Minimal data can be collected during 

routine interaction with participants without putting 

extra burden on the staff or participants; mobile 

devices can be used to facilitate data collection.53

• Evidence from the Harm Reduction Coalition 

suggests linking an SSP to research participation 

is counterproductive when providing services. Any 

research involving PWID at an SSP should be limited 

to a small number of participants and captured for 

periodic evaluation only.38

Low-threshold service delivery

• There are multiple ‘thresholds’ that participants 

have to overcome to successfully access services, 

including the registration threshold (experience 

on arrival), the competence threshold (awareness 

of needs), the efficiency threshold (effectiveness 

of service), and the trust threshold (quality of 

relationship with service provider). All SSPs should 

strive to address each of these barriers in order to 

provide truly ‘low-threshold’ services.54

• Low-threshold delivery includes maximizing access 

(service location and hours) and ensuring anonymity 

and no requirements for participation in other 

services. SSPs in Colorado have prioritized keeping 

encounter-level data minimal in order to provide 

low-threshold access to syringe exchange, outreach, 

and education services.52
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 20

VOICES FROM THE FIELD

“We want people to be able to walk in and out within 

60 seconds if they want — so we’re really focused 

on making sure that any information we’re collecting 

is worthwhile, that there’s a point. We don’t want 

people to have to feel burdened with having to give up 

anything extra we honestly don’t need.” 

– Former Community-Based SSP Director, North Carolina

“I think the people should keep a close accounting of 

the number of people they reach and the services that 

people are able to access. I think one thing people 

who don’t really like needle exchange focus on [is] the 

exchange of needles and I always tell people that like 

ten percent of the program is the exchange of needles. 

This is just a comprehensive home a touch point.” 

– Community-Based SSP Director, Florida

“There are so many levels of success with harm 

reduction. If someone says, ‘I used to use heroin, and 

now I use marijuana,’ that’s a success story. ‘I got into 

care, I got my kids back,’ that’s a success story. ‘Since I 

have to be at work at 8, I’ve learned to get up an hour 

earlier so I can use and still get to work on time and 

not get fired.’ Everything is a success story. There are 

so many different angles and vantage points, for the 

participants who are coming in. All of this is success.” 

– Public Health SSP Coordinator, Kentucky
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 21

STRATEGY V Sustainability

SSPs face several social, structural, and political 

barriers to implementation. Strong relationships with 

a variety of community partners and stakeholders 

are essential for ensuring overall program success 

and long-term sustainability. First, they address the 

concerns of the community and help achieve a sense 

of common purpose. Second, SSPs often have small, 

restrictive, or limited funding resources; developing 

strong relationships and building trust with local and 

regional communities and agencies plays a major 

role in expanding and diversifying funding sources. 

Sustainability of SSPs also depends on clients utilizing 

the program. Although following the evidence-based 

approaches presented in this technical package will 

do much to engage and attract clients, an effective 

outreach program is also important for both gaining 

community support and engaging PWID who are not 

using the program. 

KEY TAKEAWAYS

✔ Partnerships are key! SSPs ideally should consider 

partnering with jurisdictional health and social 

service agencies, local and regional foundations, 

community-based organizations, opioid coalitions, 

public safety, and other state entities to ensure 

program sustainability — both financially and 

socially. 

✔ Fostering relationships with a variety of 

stakeholders is critical to addressing community 

concerns and ensuring diversification of funding 

sources.

✔ Diversifying funding sources is beneficial for 

program sustainability.

✔ Health department support and legal counsel can 

play an important role in addressing community 

concerns, especially around syringe disposal.

✔ An environment of shared purpose (i.e., 

supporting rather than punishing PWUD) ensures 

stakeholders work collaboratively and not 

independently; public safety champions can play 

an influential role in changing agency attitudes 

and gaining useful support. 

✔ Outreach and community engagement can 

expand program reach and visibility, connect with 

PWID who might otherwise not come to the 

program, and improve community relationships. 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 22

Approaches 

SSPs face considerable challenges to implementation, service delivery, and overall program success. Community 

opposition, concerns, and financial difficulties can be substantial threats to sustainability. However, such barriers 

can be addressed through strong partnerships and support from key stakeholders, diversifying funding, and 

by working together with public safety and other state or jurisdictional agencies to create a sense of shared 

purpose and common goals. SSPs and syringe distribution are valuable and vital even when faced with community 

opposition. While building support is an ongoing process, a lack of initial support should not prevent providing 

syringe services to PWID. Establishing a presence in the community through outreach workers or other outreach 

efforts can increase program visibility, educate the public about SSPs, and engage PWID who may not yet be using 

an SSP. 

APPROACH 1 Foster Relationships with a Variety of Stakeholders

Despite overwhelming evidence supporting the 

effectiveness of SSPs, programs continue to face 

considerable challenges. Ultimately, the success of 

SSPs depends on their relationships with community 

partners and other stakeholders. Outreach to, and 

partnerships with, local/regional agencies, communitybased organizations, and other SSPs/harm reduction 

organizations are vital in addressing such community 

concerns as syringe disposal. It is important for 

programs to identify and work closely with legal counsel 

in order to address any legal challenges. Similarly, 

partnerships with researchers can be extremely 

beneficial and provide useful information to improve 

current and future services. Such research partnerships 

should align with the mission and vision of the SSP 

and ideally involve some form of compensation for 

participants and the program itself.

Strong partnerships with a variety of stakeholders is also 

important for purposes of diversifying funding sources 

and ensuring long-term sustainability of the program. 

SSPs often work with limited, restricted funding that 

may fund aspects of the program but not the entire 

SSP. Innovative partnerships with diverse stakeholders 

can not only open additional funding streams, services, 

and resources, but also help identify federal, state, 

local, and private grant opportunities. Most funding will 

stream into a specific activity, such as HIV or hepatitis C 

testing. Programs should make every effort to be aware 

of new funding opportunities that improve overall 

sustainability and expand services provided. A close 

network of supporters and stakeholders can help keep 

programs informed of opportunities. 

Programs should also conduct outreach in the 

communities where they are providing services, open 

lines of communication with their neighbors, and work 

to incorporate constructive feedback into programmatic 

activities. Establishing an outreach presence can 

help inform local PWID about available services, 

build confidence in the program among the PWID 

community, and engage PWID who are not coming into 

the SSP. Engaging in the community also can help the 

program be aware of changes in where local PWID are 

residing, what drugs are being used in the community, 

and what services are most needed. In providing 

services and engaging with the PWID population 

outside of the SSP, community members can also 

better understand the services these programs provide 

and the benefits of SSPs, further building stakeholder 

support. 

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Diversification of funding sources

• Lack of local support, uncertainty around 

coordinating with local/state governments, and local 

politics have been identified as major barriers to 

obtaining state or public SSP funding.55

• The Homeless Youth Alliance (HYA) — the only 

grassroots harm reduction coalition designed by and 

for underserved youth experiencing homelessness in 

San Francisco — used diverse and innovative funding 

streams, including foundations, donations, local 

government, and grants for violence prevention, 

food insecurity and creative arts to sustain the 

program. In 2018, the agency received a housing 

contract from the city, which provided housing to 

many of its participants.56 

• Creativity and diversification with funding streams 

can be used to provide a wide range of services at 
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 23

SSPs, even in political or policy environments that 

are not particularly supportive.33

• Diverse community partnerships and funding 

support from private citizens and city or county 

sources have been cited as major contributors to the 

financial stability and growth of Point Defiance — the 

first publicly funded needle exchange program in the 

United States.57

Addressing community concerns.

• Community-acquired needlestick injuries are 

perceived as a vital concern by community members 

and politicians25; however, an 8-year national study 

revealed that only 0.0007% of the US population 

had sought emergency medical care for a needlestick 

injury acquired in the community.

• Partnerships and effective communication with law 

enforcement, elected officials, business leaders, 

public health, the medical community, PWID and 

family/friends, and the faith community can address 

a variety of community concerns.58

• One study analyzing SSP implementation models 

found coalition building and community consultation 

as critical steps for program sustainability.2

• A core component of street outreach may 

include cleaning up any used injection equipment 

from streets and parks.59 This can help improve 

community relations, stakeholder support, and 

overall community health. 

• Outreach efforts can also educate the community 

and cultivate support. The Chicago Recovery Alliance 

uses outreach to connect with PWID and other 

community members, businesses, churches, and 

other organizations, and incorporates feedback from 

communities served into their programs.59

APPROACH 2 Create a Sense of Shared Purpose to Reduce Stigma

Attitudes and actions of public safety, including law 

enforcement agencies, can have substantial impact 

on an SSP’s success. SSPs can draw on relationships 

established with community members, policymakers, 

and other stakeholders to build support among these 

groups. Identifying a public safety champion can be an 

effective strategy to change attitudes and perceptions 

regarding SSPs and to gain useful support. 

In addition, local businesses, neighborhood residents, 

faith-based organizations, schools, elected officials, 

public safety agencies, and other individuals/agencies 

can have varying opinions regarding SSPs, and efforts 

to establish a shared goal and sense of common 

purpose with these groups can ensure SSP support 

and sustainability. Building useful partnerships with a 

wide range of stakeholders and creating opportunities 

for education and training can create consensus on 

the value of harm reduction programs and regarding 

the health of people who use drugs. The resulting 

environment can positively shape beliefs and attitudes, 

reduce stigma, and ensure the wellbeing of participants, 

program staff, and the population at large.

EVIDENCE OF EFFECTIVENESS IN ACHIEVING 

INTENDED OUTCOMES

Law enforcement and public safety buy-in and support 

• Punitive law enforcement policies and attitudes 

can adversely impact SSP goals. Davis et al. 

found that both number of SSP participants and 

number of syringes accessed decreased after every 

police intervention designed to disrupt open-air 

drug markets in Philadelphia — importantly, SSP 

participation by black participants decreased 

twice as much as that by whites and use by males 

decreased twice as much as that by females, 

exacerbating health disparities.60

• Davis and Beletsky reported that a brief police 

training intervention that combined information 

about public health benefits and legality of SSPs 

with officer concerns about infectious diseases 

and occupational safety (needlesticks) resulted in 

improved communication and collaboration between 

the two institutions.61

• Beletsky et al. reported that trainings that combine 

police officers’ concerns about occupational safety 

with public health’s harm reduction goals can help 

improve attitudes about the benefits of syringe 

access and SSPs.62
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 24

Collaboration with broad stakeholder groups improves 

health for communities of PWID

• With proper training, understanding, and 

communication, public safety entities can play a 

major role as a public health partner by directing 

people found with illicit drugs to SSPs and treatment 

programs rather than arresting and detaining them.3

• The Harm Reduction Action Center (HRAC) in 

Denver, Colorado used local police department’s 

support, which came in the form of a harm reduction 

champion from within the department, to address 

neighborhood concerns and successfully entered 

into a Good Neighbor agreement with the local 

neighborhood association. HRAC provided services 

in that neighborhood for 3 years.63,64

VOICES FROM THE FIELD

“Another person described their local sheriff as initially 

threatening to jail anyone who tried to operate an 

SSP, but after open conversation, they realized what 

he wanted was transparency — open bylaws and 

awareness of what was really occurring at the SSP. ‘I 

have a great relationship with him now; he’s very, he’s 

one of our biggest allies now, to be honest with you.’” 

– Community-Based SSP Director, Utah

“It builds our credibility when we have these 

relationships, so I can call on these folks if we need 

them to back us up.” 

– Former Community-Based SSP Director, Indiana

“We’ve had a lot of funders send people from red and 

purple states to us to learn about how we hustle and 

do our thing. So sometimes what would be helpful 

with the funders if they can’t do a large investment is 

to invest in helping new programs that are interested, 

and potential future groups that could be funded, to 

provide them with some kind of mentorship to help 

build up programs’ capacity to hustle and to help build 

up programs’ understanding of how to do things with 

very little money. They should constantly be helping 

programs to learn.” 

– Former Community-Based SSP Director, North Carolina

“We are authorized by law to do these things, but we 

live in a political and economic reality. People have to 

know that, and adjust accordingly. You definitely want 

as many advisors as possible in your planning process. 

Multiple agencies — that’s one way to help prevent a 

crash and burn.” 

– Health Department-Run SSP, West Virginia

“We hired a lawyer who worked in the Attorney 

General’s office and worked in a unit that worked 

on human trafficking, sex crimes, those types of 

things. And then he was a prosecutor with the Salt 

Lake County DA’s office. So we’re leveraging his 

relationships throughout the state to help mediate 

concerns with law enforcement, add some credibility 

to our program, add some protection for our staff, so 

that if something happens we have representation 

immediately. So that’s been helpful.” 

– Community-Based SSP Director, Utah

“I believe very heavily in the good neighbor agreement. 

It’s very awkward initially because you sit down with 

a mediator, law enforcement, some neighbors — then 

talk about what you’re going to do and how you’re 

going to do it. And then everybody signs off and then 

they allow you to just do it and implement it. I like that. 

Because honestly the Good Neighbor agreements are 

very nebulous but people feel heard.” 

– Community-Based SSP Director, Colorado

“My goal is to get a meeting with the residents to 

start to humanize the problem to be like, ‘We’re your 

neighbors! Everyone here is your neighbor.’” 

– Community-Based SSP Director, California
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 25

Additional Resources

Figure 1. Pros and cons of service delivery models

DELIVERY 

MODEL PROS CONS

Fixed site/

Storefront

• Fixed-site models work best in locations 

where PWID are gathered and allow for 

easier integration of or referral to ancillary 

support services

• Set location with predictable hours allows 

easier access

• Visibility can be a barrier due to concerns 

about stigma

• A brick-and-mortar design can be costly to 

maintain

• Transportation to site can be a barrier

• Fixed sites based in clinics or other 

healthcare settings may deter participants 

due to previous experiences of stigma or 

poor treatment

Mobile Unit/

Outreach

• Mobile Units or Outreach can reach 

targeted groups of people who might face 

transportation issues or fear stigma from 

accessing fixed sites

• Brings services to people rather than asking 

them to come to services

• Cost of unit

• Limited expanded services able to be 

offered with some forms of outreach

• Varying schedule can make it harder for 

participants to remember where and when 

services are available

Secondary 

exchange/

delivery

• Secondary exchange models deliver services 

for large areas and sparsely distributed 

PWID populations that are difficult to cover 

with traditional delivery models

• May reach PWID who will not go to fixedsite SSPs

• Additional considerations include training 

and oversight of secondary exchangers, and 

legal framework.

• May be more challenging to support 

participants to get HCV, HIV testing, other 

expanded services

Mobile/

Backpack

• Mobile models allow for service delivery to 

PWID in discreet/rural areas, populations 

with limited transportation access and/or 

areas with low PWID density

• Cost might be based on distance, resources 

needed (e.g., car, van, gasoline, or insurance, 

etc.) and frequency of visits

• Service delivery schedule is subject to 

weather or other unforeseen circumstances; 

keeping up with the delivery location and 

times might be challenging for participants

• May be more challenging to support 

participants to get HCV, HIV testing, other 

ancillary services

Secondary 

Exchange, 

combined 

with Fixed or 

Mobile model

• Multiple options for service delivery (both 

core and expanded)

• Flexibility for participants, given their 

current circumstances and context

• Different levels of engagement options can 

ensure access to comprehensive services

• Potential for increased training and support 

for secondary exchangers

• Maintenance of multiple service delivery 

models might increase program operating 

costs or staffing needs
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 26

Figure 2. Need-based versus 1:1 exchange: Why restrictive 

syringe exchange is not the preferred approach?

CDC factsheet 

(Coming soon — in CDC clearance now)
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 27

Box A-1. Designing an SSP: What to 

Consider?

• Burden: PWID prevalence; infectious disease rates 

among PWID

• PWID characteristics: age, race/ethnicity, 

gender, cultural and linguistic barriers, vulnerable 

populations, drug use characteristics

• Vulnerable populations: adolescents, elderly, 

pregnant women, comorbid mental and substance 

use disorders

• Resources: workforce, funding (available or required) 

• Partnerships: health departments, local/state/

national agencies, CBOs, MOUD programs, elected 

officials, law enforcement 

• Local policies, politics, and practices 

OTHER PUBLISHED RESOURCES 

ON SSP PLANNING, DESIGN AND 

IMPLEMENTATION

1. US Department of Health and Human Services. 

Department of Health and Human Services 

Implementation Guidance to Support Certain 

Components of Syringe Services Programs, 2016. 

https://www.hiv.gov/sites/default/files/hhs-sspguidance.pdf

2. National Alliance of State and Territorial AIDS 

Directors. Syringe Services Program (SSP) 

Development and Implementation Guidelines 

for State and Local Health Departments. https://

www.nastad.org/sites/default/files/resources/

docs/055419_NASTAD-SSP-GuidelinesAugust-2012.pdf

3. Centers for Disease Control and Prevention. Syringe 

Services Programs (SSPs) Developing, Implementing, 

and Monitoring Programs. https://www.cdc.gov/hiv/

pdf/risk/cdc-hiv-developing-ssp.pdf

4. Comer Family Foundation. A Guide to Establishing 

Syringe Services Programs in Rural, At-Risk Areas. 

http://www.comerfamilyfoundation.org/img/AGuide-to-Establishing-Syringe-Services-Programsin-Rural-At-Risk-Areas.pdf

5. New York City Department of Health and Mental 

Hygiene. Recommended Best Practices for 

Effective Syringe Exchange Programs in the United 

States. https://harmreduction.org/wp-content/

uploads/2012/01/NYC-SAP-Consensus-Statement.

pdf

6. Harm Reduction Coalition. Guide to Developing 

and Managing Syringe Access Programs, www.

harmreduction.org

7. National Governor’s Association. State Approaches 

to Addressing the Infectious Disease Consequences 

of the Opioid Epidemic. https://www.nga.org/

wp-content/uploads/2019/05/NGA-Brief-StateApproaches-to-Addressing-Infectious-DiseaseMay-2019-002.pdf

8. Centers for Disease Control and Prevention. 

Infectious Diseases, Opioids and Injection Drug 

Use. https://www.cdc.gov/pwid/opioid-use.html

9. Centers for Disease Control and Prevention. 

Persons Who Inject Drugs. https://www.cdc.gov/

pwid/disease-prevention.html

10. Open Society Foundations. Harm Reduction 

at Work: A Guide for Organizations Employing 

People Who Use Drugs. https://www.

opensocietyfoundations.org/uploads/170e646dbcc0-4370-96d7-7cf2822a1869/workharmreduction-20110314.pdf

11. Harm Reduction Coalition, New York City 

Department of Health and Mental Hygiene & 

Bureau of Alcohol and Drug Use Prevention, 

Care and Treatment. Peer-exchange Syringe 

Delivered Toolkit Models, Considerations, and Best 

Practices, https://harmreduction.org/wp-content/

uploads/2012/11/pdse-toolkit-with-links.pdf

12. CDC Program Guidance for Implementing Certain 

Components of Syringe Services Programs, 2016: 

https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-syringeexchange-services.pdf
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 28

References

1. Frieden TR. Six components necessary for effective public health 

program implementation. Am J Public Health. 2014;104(1):17-22. 

doi:10.2105/AJPH.2013.301608

2. Downing M, Riess TH, Vernon K, et al. WHAT’S COMMUNITY 

GOT TO DO WITH IT? IMPLEMENTATION MODELS OF 

SYRINGE EXCHANGE PROGRAMS. Vol 17; 2005.

3. Carroll JJ, Green TC, Noonan RK. Evidence-Based Strategies 

for Preventing Opioid Overdose: What’s Working in the United 

States An Introduction for Public Heath, Law Enforcement, Local 

Organizations, and Others Striving to Serve Their Community. 

Retrieved from https://www.cdc.gov/drugoverdose/pdf/

pubs/2018-evidence-based-strategies.pdf 

4. Open Society Foundations. Harm Reduction at Work: A GUIDE 

FOR ORGANIZATIONS EMPLOYING PEOPLE WHO USE 

DRUGS. Retrieved from https://www.opensocietyfoundations.

org/uploads/170e646d-bcc0-4370-96d7-7cf2822a1869/workharmreduction-20110314.pdf

5. Peer-Delivered Syringe Exchange ToolKit Models, Considerations, and 

Best Practices. Retrieved from https://harmreduction.org/wpcontent/uploads/2012/11/pdse-toolkit-with-links.pdf

6. Benyo A. PROMOTING SECONDARY EXCHANGE: Opportunities to 

Advance Public Health. Retreived from https://harmreduction.org/

wp-content/uploads/2012/01/promotingsecondaryexchange.

pdf.

7. Murphy S, Kelley MS, Lune H. The health benefits of secondary 

syringe exchange. J Drug Issues. 2004;34(2):245-268. 

doi:10.1177/002204260403400201

8. Ashford RD, Curtis B, Brown AM. Peer-delivered harm reduction 

and recovery support services: Initial evaluation from a hybrid 

recovery community drop-in center and syringe exchange 

program. Harm Reduct J. 2018;15(1). doi:10.1186/s12954-018-

0258-2

9. Richardson LA, Milloy MJS, Kerr TH, Parashar S, Montaner JSG, 

Wood E. Employment predicts decreased mortality among HIVseropositive illicit drug users in a setting of universal HIV care. 

J Epidemiol Community Health. 2014;68(1):93-96. doi:10.1136/

jech-2013-202918

10. Simpson EL, House AO. Involving Users in the Delivery and 

Evaluation of Mental Health Services: Systematic Review. doi: 

10.1136/bmj.325.7375.1265

11. Bardwell G, Kerr T, Boyd J, McNeil R. Characterizing peer roles 

in an overdose crisis: Preferences for peer workers in overdose 

response programs in emergency shelters. Drug Alcohol Depend. 

2018;190:6-8. doi:10.1016/j.drugalcdep.2018.05.023

12. Wood E, Kerr T, Spittal PM, et al. An External Evaluation of a PeerRun “Unsanctioned” Syringe Exchange Program. Journal of Urban 

Health: Bulletin of the New York Academy of Medicine. J Urban 

Health. 2003 Sep; 80(3): 455–464. doi: 10.1093/jurban/jtg052

13. Bardwell G, Anderson S, Richardson L, et al. The perspectives 

of structurally vulnerable people who use drugs on volunteer 

stipends and work experiences provided through a drug user 

organization: Opportunities and limitations. Int J Drug Policy. 

2018;55:40-46. doi:10.1016/j.drugpo.2018.02.004

14. Sherman SG, Gann DS, Scott G, Carlberg S, Bigg D, Heimer R. A 

qualitative study of overdose responses among Chicago IDUs. 

Harm Reduct J. 2008;5. doi:10.1186/1477-7517-5-2

15. Tzemis D, Al-Qutub D, Amlani A, Kesselring S, Buxton JA. A 

quantitative and qualitative evaluation of the British Columbia 

Take Home Naloxone program. C Open. 2014;2(3):E153-E161. 

doi:10.9778/cmajo.20140008

16. Marshall C, Perreault M, Archambault L, Milton D. Experiences of 

peer-trainers in a take-home naloxone program: Results from a 

qualitative study. Int J Drug Policy. 2017;41:19-28. doi:10.1016/j.

drugpo.2016.11.015

17. Kerr T, Small W, Buchner C, et al. Syringe sharing and HIV 

incidence among injection drug users and increased access to 

sterile syringes. Am J Public Health. 2010;100(8):1449-1453. 

doi:10.2105/AJPH.2009.178467

18. Hyshka E, Strathdee S, Wood E, Kerr T. Needle exchange and the 

HIV epidemic in Vancouver: Lessons learned from 15 years of 

research. Int J Drug Policy. 2012;23(4):261-270. doi:10.1016/j.

drugpo.2012.03.006

19. Barocas, J. A., Baker, L., Hull, S. J., Stokes, S., & Westergaard, R. 

P. (2015). High uptake of naloxone-based overdose prevention 

training among previously incarcerated syringe-exchange 

program participants. Drug Alcohol Depend, 154, 283-286. 

doi:10.1016/j.drugalcdep.2015.06.023

20. Bruneau J, Lamothe F, Franco E, et al. ORIGINAL 

CONTRIBUTIONS High Rates of HIV Infection among Injection 

Drug Users Participating in Needle Exchange Programs in Montreal: 

Results of a Cohort Study. Vol 146.; 1997. Retrieved from https://

academic.oup.com/aje/article-abstract/146/12/994/111523.

21. Wood E, Tyndall MW, Spittal PM, et al. Needle Exchange and 

Difficulty with Needle Access during an Ongoing HIV Epidemic. 

International Journal of Drug Policy 13 (2002) 95-102. www.

elsevier.com/locate/drugpo.

22. Bluthenthal RN, Ridgeway G, Schell T, Anderson R, Flynn NM, 

Kral AH. Examination of the association between syringe 

exchange program (SEP) dispensation policy and SEP clientlevel syringe coverage among injection drug users. Addiction. 

2007;102(4):638-646. doi:10.1111/j.1360-0443.2006.01741.x

23. Kral AH, Anderson R, Flynn NM, Bluthenthal RN. Injection 

Risk Behaviors Among Clients of Syringe Exchange Programs 

With Different Syringe Dispensation Policies. JAcquir Immune 

Defic Syndr 2004;37:1307–1312. DOI: 10.1097/01.

qai.0000127054.60503.9a.

24. Bluthenthal RN, Anderson R, Flynn NM, Kral AH. Higher syringe 

coverage is associated with lower odds of HIV risk and does 

not increase unsafe syringe disposal among syringe exchange 

program clients. Drug Alcohol Depend. 2007;89(2-3):214-222. 

doi:10.1016/j.drugalcdep.2006.12.035

25. Quinn B, Chu D, Wenger L, Bluthenthal RN, Kral AH. Syringe 

disposal among people who inject drugs in Los Angeles: The role 

of sterile syringe source. Int J Drug Policy. 2014;25(5):905-910. 

doi:10.1016/j.drugpo.2014.05.008

26. Lorvick J, Bluthenthal R, Scott A, et al. Secondary syringe 

exchange among users of 23 California syringe exchange 

programs. Subst Use Misuse. 2006;41(6-7):865-882. 

doi:10.1080/10826080600669041
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 29

27. De P, Cox J, Boivin JF, Platt RW, Jolly AM. Social network-related 

risk factors for bloodborne virus infections among injection drug 

users receiving syringes through secondary exchange. J Urban 

Heal. 2008;85(1):77-89. doi:10.1007/s11524-007-9225-z

28. Grau LE, Bluthenthal RN, Marshall P, Singer M, Heimer R. 

Psychosocial and behavioral differences among drug injectors 

who use and do not use syringe exchange programs. AIDS Behav. 

2005;9(4):495-504. doi:10.1007/s10461-005-9020-3

29. Heller DI, Paone D, Siegler A, Karpati A. The syringe gap: An 

assessment of sterile syringe need and acquisition among syringe 

exchange program participants in New York City. Harm Reduct J. 

2009;6. doi:10.1186/1477-7517-6-1

30. Rich JD, Strong L, Towe CW, McKenzie M. Obstacles to needle 

exchange participation in Rhode Island. J Acquir Immune Defic 

Syndr. 1999,Aug15; 21(5):396-400. PMID: 10458620.

31. Wilson D, Halperin DT. “Know your epidemic, know your 

response”: a useful approach, if we get it right. doi:10.1016/

S0140

32. Howard Center Safe Recovery. Retrieved from https://www.

healthvermont.gov/sites/default/files/documents/pdf/OCC_

Howard%20Center%20Low%20Barrier%20Buprenorphine.pdf 

33. Burr CK, Storm DS, Hoyt MJ, et al. Integrating Health and 

Prevention Services in Syringe Access Programs: A Strategy 

to Address Unmet Needs in a High-Risk Population. doi: 

10.1177/00333549141291S105

34. Kidorf M, Van; King L. Expanding the Public Health Benefits of 

Syringe Exchange Programs. Can J Psychiatry 2008;53(8):487–495 

35. Kidorf M, King VL, Pierce J, Kolodner K, Brooner RK. Benefits 

of concurrent syringe exchange and substance abuse treatment 

participation. J Subst Abuse Treat. 2011;40(3):265-271. 

doi:10.1016/j.jsat.2010.11.011

36. National Governor’s Association. State Approaches to 

Addressing the Infectious Disease Consequences of the Opioid 

Epidemic. Retrieved from https://www.nga.org/wp-content/

uploads/2019/05/NGA-Brief-State-Approaches-to-AddressingInfectious-Disease-May-2019-002.pdf.

37. Des Jarlais DC. “Single-use” needles and syringes for the 

prevention of HIV infection among injection drug users. J Acquir 

immune Defic Syndr Hum retrovirology. 1998;18 Suppl 1:S52-6.

38. Bluthenthal R, Clear A, Des Jarlais D, et al. Recommended Best 

Practices for Effective Syringe Exchange Programs in the United 

States. NYC Department of Health and Mental Hygiene. 2009.

39. Coffin P, Latka MH, Latkin C, et al. Safe syringe disposal is 

related to safe syringe access among HIV-positive injection drug 

users. AIDS Behav. 2007;11(5):652-662. doi:10.1007/s10461-

006-9171-x

40. World Health Organization. Management of Substance Abuse 

Team, World Health Organization. Community Management 

of Opioid Overdose. Retrieved from https://apps.who.int/iris/

bitstream/handle/10665/137462/9789241548816_eng.pdf.

41. Rowe C, Santos GM, Vittinghoff E, Wheeler E, Davidson P, 

Coffin PO. Predictors of participant engagement and naloxone 

utilization in a community-based naloxone distribution program. 

Addiction. 2015;110(8):1301-1310. doi:10.1111/add.12961

42. Keane C, Egan JE, Hawk M. Effects of naloxone distribution to 

likely bystanders: Results of an agent-based model. Int J Drug 

Policy. 2018;55:61-69. doi:10.1016/j.drugpo.2018.02.008

43. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates 

and implementation of overdose education and nasal naloxone 

distribution in Massachusetts: Interrupted time series analysis. 

BMJ. 2013;346(7894). doi:10.1136/bmj.f174

44. Behar E, Santos GM, Wheeler E, Rowe C, Coffin PO. Brief 

overdose education is sufficient for naloxone distribution 

to opioid users. Drug Alcohol Depend. 2015;148:209-212. 

doi:10.1016/j.drugalcdep.2014.12.009

45. Hagan H, Ph D, Mcgough JP, et al. Reduced injection frequency 

and increased entry and retention in drug treatment associated 

with needle-exchange participation in Seattle drug injectors. J 

Subst Abuse Treat. 2000;19(3):247-252. http://www.ncbi.nlm.nih.

gov/pubmed/11027894. Accessed March 6, 2020.

46. Strathdee SA, Celentano DD, Shah N, et al. Needle-exchange 

attendance and health care utilization promote entry into 

detoxification. J Urban Heal. 1999;76(4):448-460. doi:10.1007/

BF02351502

47. Heimer R. Can syringe exchange serve as a conduit to substance 

abuse treatment? J Subst Abuse Treat. 1998;15(3):183-191. 

doi:10.1016/S0740-5472(97)00220-1

48. Kidorf M, King VL, Peirce J, Kolodner K, Brooner RK. A treatment 

reengagement intervention for syringe exchangers. J Subst Abuse 

Treat. 2011;41(4):415-421. doi:10.1016/j.jsat.2011.06.008

49. Bachhuber MA, Thompson C, Prybylowski A, Benitez J, Mazzella 

S, Barclay D. Description and outcomes of a buprenorphine 

maintenance treatment program integrated within Prevention 

Point Philadelphia, an urban syringe exchange program. Subst 

Abus. 2018;39(2):167-172. doi:10.1080/08897077.2018.14435

41

50. Department of Health and Human Services. Implementation 

Guidance to Support Certain Components of Syringe Services 

Programs, 2016. Retrieved from https://www.hiv.gov/sites/

default/files/hhs-ssp-guidance.pdf. Accessed March 06, 2020. 

51. Harm Reduction Coalition. Guide to Developing and Managing 

Syringe Access Programs.; 2010. www.harmreduction.org.

52. The Works Program - Boulder County. https://www.

bouldercounty.org/families/disease/the-works-program/. 

Accessed March 6, 2020.

53. O’Keefe D, Bluthenthal RN, Kral AH, Aitken CK, McCormack 

A, Dietze PM. Measures of harm reduction service provision 

for people who inject drugs. Bull World Health Organ. 

2019;97(9):605-611. doi:10.2471/BLT.18.224089

54. Edland-Gryt M, Skatvedt AH. Thresholds in a low-threshold 

setting: An empirical study of barriers in a centre for people with 

drug problems and mental health disorders. Int J Drug Policy. 

2013;24(3):257-264. doi:10.1016/j.drugpo.2012.08.002

55. Green TC, Martin EG, Bowman SE, Mann MR, Beletsky L. Life 

after the ban: An assessment of US syringe exchange programs’ 

attitudes about and early experiences with federal funding. Am J 

Public Health. 2012;102(5):e9. doi:10.2105/AJPH.2011.300595

56. Homeless Youth Alliance | San Francisco. https://www.

homelessyouthalliance.org/. Accessed March 6, 2020.
Syringe Services Programs: A Technical Package of Effective Strategies and 

Approaches for Planning, Design, and Implementation 30

57. Sherman SG, Purchase D. Point Defiance: A case study of 

the United States’ first public needle exchange in Tacoma, 

Washington. Int J Drug Policy. 2001;12(1):45-57. doi:10.1016/

S0955-3959(00)00074-8

58. Comer Family Foundation. A Guide to Establishing Syringe Services 

Programs in Rural, At-Risk Areas. 2017. Retrieved from http://

harmreduction.org/ruralsyringe/wp-content/uploads/Guide-toEstablishing-Syringe-Services-Programs-in-Rural-At-Risk-Areas.

pdf

59. Chicago Recovery Alliance. Harm Reduction Outreach with Syringe 

Exchange – Guidelines and Operating Procedures. 2018. Retrieved 

from http://anypositivechange.org/wp-content/uploads/

guideOP.pdf

60. Davis CS, Burris S, Kraut-Becher J, Lynch KG, Metzger D. Effects 

of an intensive street-level police intervention on syringe 

exchange program use in Philadelphia, Pa. Am J Public Health. 

2005;95(2):233-236. doi:10.2105/AJPH.2003.033563

61. Davis CS, Beletsky L. Bundling occupational safety with harm 

reduction information as a feasible method for improving police 

receptiveness to syringe access programs: Evidence from three 

U.S. cities. Harm Reduct J. 2009;6:16. doi:10.1186/1477-7517-

6-16

62. Beletsky L, Agrawal A, Moreau B, Kumar P, Weiss-Laxer 

N, Heimer R. Police training to align law enforcement and 

HIV prevention: Preliminary evidence from the field. Am 

J Public Health. 2011;101(11):2012-2015. doi:10.2105/

AJPH.2011.300254

63. Winkler JM. Harm Reduction Action Center. Metro. http://

harmreductionactioncenter.org/. Published 2010. Accessed 

March 6, 2020.

64. Meltzer E. How Denver supervised injection sites could help 

addicts live to fight another day. - Denverite. https://denverite.

com/2017/11/06/denver-supervised-injectionsites/. Published 

2017. Accessed March 6, 2020.